Online Patient Registration Form

Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

IMPORTANT- WHAT YOU SHOULD BRING TO YOUR APPOINTMENT! ALL PATIENTS MUST BRING ALL GLASSES INCLUDING SUNGLASSES TO THEIR APPOINTMENT! CONTACT LENS WEARERS: MUST WEAR THEIR LENSES TO THEIR APPOINTMENT AND BRING ALL GLASSES INCLUDING SUNGLASSES! NEW PATIENTS MUST BRING CONTACT LENS BOXES AS WELL!

Please ensure you also fill out either the Child Visual Efficiency Checklist or the Adult Visual Efficiency Checklist as applicable. If applicable, please fill out the Neuro-Related Visual Skills Checklist as well.

Contact Information

First Name *

Last Name *

Address 1 *

Address 2

City *

State / Province *

Zip / Postal Code *

Primary Telephone *

Secondary Telephone

Pager Number

Fax Number

Email Address *

Personal Information

Gender *

Date of Birth (MM/DD/YYYY) *

Social Security Number (last 4 digits)

Marital Status

Employment

Employer

Occupation

How were you referred to our office? *

If other, please describe:

Eye History

Please check off any current conditions you suffer from:

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Headaches

Glare/Light Sensitivity

Tired Eyes

Amblyopia (lazy eye)

Burning

Dryness

Watery Eyes

Eye Pain and/or Soreness

Foreign Body Sensation

Infection of Eye or Lid

Itching

Mucous Discharge

Drooping eyelid(s)

Redness

Sandy or Gritty Feeling

Strabismus (crossed eye)

Blurred Vision at Distance

Blurred Vision at Near

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

How many hours a day do you use a computer?

How many inches away, approximately, do you sit from your computer monitor?

Glasses History (Skip if you don't wear glasses.)

What glasses do you own?

Single Vision

Bifocals

Safety Glasses

Backup Glasses

Progressive

Trifocals

Sports Glasses

Sunglasses

Other

If other, please describe:

Please check off any current conditions you suffer from

I am having problems with my current glasses.

There are times when I would rather not be wearing glasses.

I have problems with glare.

I have problems with night vision.

I am allergic to nickel (e.g. frames of glasses).

I don’t have a spare set of glasses.

My spare glasses have an incorrect prescription.

My sunglasses are missing UV (ultra-violet) protection.

Contact Lens History (Skip if you don't wear contacts.)

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule?

Hours/day

Days/week

Please check off all that apply to you

I am having problems with my current contact lenses.

There are times when I would rather not be wearing contact lenses.

I am interested in changing or enhancing my eye color.

I am interested in a non-surgical method of vision correction.

I am interested in refractive laser surgery.

I don't have a spare set of contact lenses.

My spare contact lenses have an incorrect prescription.

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Our patient forms are available online so they can be completed in the convenience of your own home or office.

Office Hours

Day

Open

Closed

Monday

10 am

7 pm

Tuesday

9 am

6 pm

Wednesday

VT Only

VT Only

Thursday

9 am

6 pm

Friday

9 am

2 pm

Saturday

By Appt.

By Appt.

Sunday

Closed

Closed

Day

Open

Closed

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

10 am

9 am

VT Only

9 am

9 am

By Appt.

Closed

7 pm

6 pm

VT Only

6 pm

2 pm

By Appt.

Closed

Patient Portal

Testimonial

"Dr. Sapossnek is an excellent optometrist. She has my complete trust. She is so thorough in her exams and includes parents in conversation and education, so I know and understand all the facets of my children's vision. All of the above [in the Patient Satisfaction Survey are] EXCELLENT, no need to elaborate. I feel fortunate to have found Dr. Sapossnek and am glad all of us can go to her-both for my child with vision therapy needs, daughter and I with glasses, and son who needs neither."